H I G H L I G H T S

Presented by The Mental Health Funders Collaborative

T H E S T A T U S O F

Mental Health CareI N C O L O R A D O

Eight Colorado grantmaking foundationsformed a unique collaborative to studythe mental health care needs in the state.Foundations participating in the MentalHealth Funders Collaborative include:

• Caring for Colorado Foundation

• The Colorado Trust

• Daniels Fund

• First Data Western UnionFoundation

• HealthONE Alliance

The Mental Health Funders Collaborativestudy found some alarming trends withinColorado’s complex, fragmented array of mental health systems and providers:

G R O W I N G N E E D S

• One out of five people in Coloradoneeds mental health services eachyear, yet fewer than a third of themreceive care. The lack of care resultedin suicide, lost productivity andhomelessness, among other costs,for many of the 600,000 Coloradanswho went untreated in 2000.

• Children and adolescents make upnearly one quarter of Colorado’spopulation, but experience overone-third of the severe mentalhealth needs in the state. Only halfof children from families with bothlow incomes and severe levels ofneed received care in 2000.

Trends

• Rose Community Foundation

• Rose Women’s Organization

• The Denver Foundation, with support from the following funds:Ryan Briggs Memorial Foundation,Diana Burk Vickery CharitableFoundation, N.E.A.R. Fund and theJohn Jenkins & Debra Lappin Fund.

The collaborative commissioned TriWestGroup to conduct the assessment andcritical analysis of the public and privatemental health systems in Colorado.TriWest interviewed 150 key informantsacross the state and multiple stakeholdergroups, conducted statewide focus groups

with over 110 additional consumers and family members, surveyed more than220 Colorado providers and reviewed320 state and national published andunpublished sources.

Findings of this study will allow collab-orative members, and others across thestate who work to support and improvemental health, to better understand thestrengths and weaknesses of Colorado’ssystems and services in order to identifyopportunities to strengthen them. Whatfollows are highlights from the fullreport, The Status of Mental Health Care

in Colorado.

S H R I N K I N GR E S O U R C E S

• In 2001, Colorado ranked 31stnationally for publicly funded mentalhealth care, spending just over $64per capita – 21% below the nationalaverage of $81 per capita.

• Public mental health spendingcontinues to lose ground as a resultof state budget cuts. Per capitaspending for non-Medicaid care wascut 17% in 2002 and is expected tofall nearly 7% more in the 2003-04state fiscal year, which will likelyresult in nearly 10,000 fewer peoplebeing served in 2004.

• Publicly funded state hospitalcapacity has eroded significantly.Over one-third of adolescent capacityand over one-fourth of adult capacitywere cut between July 2002 andJuly 2003 – with virtually no costsavings to the state.

• After falling in proportion to overallhealth care spending throughoutthe 1990s, private mental healthbenefits are now being furthertrimmed as part of a broaderresponse by employers to reducetheir health care costs.

I N A C C E S S I B L E &I N A D E Q U A T E C A R E

• Significant disparities exist in access to mental health care forracial, ethnic and sexual minoritygroups, for people with disabilities,and for people living in rural areasof the state.

• A great number of services that areknown to be effective are not widelyavailable, often because such servicesare more expensive.

• Colorado lacks child psychiatristsand other providers with specializedskills. Shortages are most acute forchildren and older adults, and inrural areas of the state.

B ackground

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Mental health funding in Colorado was the most frequently mentioned concern am ong key informants ;

m o s t c a l l e d i t a c r i s i s .Study findings current as of July 2003.

O N E :

Th e r e I s a N e e d for Coord inat ion and Integrat ion

There is no single mental health systemin Colorado. The “mental health system”is actually many fragmented systems,including public mental health providers,largely funded by the government; privatemental health providers, largely fundedby private insurance and people who payfor their own care; and other systems of care that are not designated mentalhealth systems, but which actually providemore mental health services than the twoformal mental health systems combined.

T W O :

Many People Cannot Acces s Needed Care

In 2000, one in five Coloradans (900,000people) needed mental health care, yetless than one-third of them receivedservices. Of these individuals in need ofmental health services, more than 250,000have been identified as being in severeneed, meeting criteria established bythe Mental Health Services of Colorado.Denver and the Western Slope have thehighest per capita rates of severe mentalhealth needs; however, there are far fewerservices available per capita on theWestern Slope to meet this high need.

The system does no better in terms of meeting an array of special needs.Children and adolescents make up nearlyone quarter of Colorado’s populationand experience over one-third of thesevere needs. However, a higher propor-tion of adults with severe needs receivecare (two-thirds) than do children (justover half) or older adults (just underhalf). And, while overall rates of mentalhealth needs do not seem to differ byracial or ethnic group, disparities in accessto care are clear. In particular, too fewculturally and linguistically competentproviders are available for the one infour Coloradans who are Latino, AfricanAmerican, Asian American, PacificIslander or American Indian. In addition,the mental health needs of gay, lesbian,bisexual and transgendered people, as wellas people with disabilities, are higher forstress-related conditions and they experi-ence systematic barriers to effective care.

Overall, people with the lowest incomes and most severe disorders (particularly those with Medicaid) are more thantwice as likely to receive mental healthcare than are other Coloradans.

T H R E E :

Mental Health Fund ing I s Low and Shr ink ing

Mental health funding in Colorado was the most frequently mentioned concernamong key informants; most called it a crisis. Public funding per capita was21% below the national average in 2001and has fallen sharply since, particularlyfor those with severe needs and noMedicaid. Funding for low-income people with severe needs and noMedicaid will have been slashed nearly23% between 2001 and the 2004 budgetyear. This will likely result in servicesbeing cut for nearly 10,000 people in2004. At the same time that funding forcommunity-based services is cut, moreof the people with the most severe needsare discharged from state hospitals, with27% of adult inpatient capacity and 35%of adolescent inpatient capacity havingbeen eliminated between July 2002 andJuly 2003. Even Colorado’s Medicaidprogram, which arguably offers the bestmental health coverage in the state, has begun to experience reduced funding,with thousands fewer people served instate fiscal year 2002-03 than in 2001-02. (Observations continued on page 3)

K e y Observations

P U B L I C M E N T A LH E A L T H P R O V I D E R S

(2.5 out of every 10 served)

1 7 Community Mental Health Centers

6 Other Publicly Funded Clinics

2 Colorado Mental Health Institutes

2 Veterans Administration Hospitals

8 MHASA (Medicaid) Networks

P R I V A T E M E N T A LH E A L T H P R O V I D E R S

(1.5 out of every 10 served)

2 0 Private Hospitals

7 1 3 Psychiatrists

7 , 6 4 8 Psychologists, Social Workers,Marriage & Family Therapists &

Professional Counselors

O T H E R S Y S T E M S P R O V I D I N G M E N T A L

H E A L T H S E R V I C E S

(6 out of every 10 served)

Primary Care Physicians and Providers

Substance Abuse Services

Child Welfare

Youth and Adult Corrections

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Data in graphic about

Colorado’s mental health

systems current as of

July 2003.

On the private side, even fewer peoplereceive needed mental health care. Manylack insurance altogether, but for thosewith coverage, mental health benefitspending fell in proportion to generalhealth benefits throughout the 1990s.Additionally, managed and limited mentalhealth benefits mean even those withinsurance increasingly must pay for theirown care or forgo it altogether.

F O U R :

Mental Health Cost s Are Increas ing

The cost of mental health care is increas-ing due to both health care inflation andcosts for newly available treatments.Overall, health care spending, includingmental health care, rose 8.7% between2000 and 2001. Spending on Medicaid,hospital care and prescription drugsgrew fastest, with hospital spending contributing 30% of the overall spendingincrease. Prescription spending grew

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treatment systems alike to implementthese proven services. But, these practicesare more likely to improve productivity,reduce costs for other health and humanservices and lead to better lives for thosein need of care. At the same time, manyproven or promising practices have beenimplemented in Colorado and can serveas models for the wider dissemination ofeffective care approaches. These includeassertive community treatment for adultswith serious mental illness, wraparoundplanning and blended funding for youthwith serious emotional disturbances, andintegrated depression treatment initiativesin primary care settings. These and morethan 100 other programs, practices andinterventions for children, youth, families,adults and older adults are documentedin the full report.

S I X :

Providers WithSpecialized S k i l l s A r e N e e d e d

While Colorado has more psychiatrists,social workers and psychologists percapita than most other states, there is a lack of providers with certain criticalspecialties, and providers in general toserve rural areas of the state. The currentstudy suggests a need for psychiatrists,in particular child psychiatrists. There alsois a lack of child and older adult specialistsoverall. Northeast Colorado and theWestern Slope have fewer psychiatriststhan federal standards suggest are needed. Furthermore, Latino/HispanicAmericans, African Americans and Asian Americans/Pacific Islanders areunderrepresented among providers.

O n e ou t o f f i v e p e o p l e in Colorado needs mentalhealth s erv ice s each y ear ,

y e t f e w e r t h a n a t h i r d

o f t h e m r e c e i v e c a r e .

K e yObservat ions– cont inued

at twice its overall historic rate in 2001,though most of the increase is attributableto more prescriptions being written, not to increased costs per prescription.Accordingly, insurance premiums rose10.5% in 2001, and out-of-pocketspending rose about 5%.

Referring to these growing costs only as inflation obscures the increased effectiveness of new medications andtreatments. For example, analysis ofadvances in treatment for depressionfound that the value of treatment gainsoutweighed increased costs, primarilydue to the value of the reduced timepatients spend depressed.

F I V E :

Many Mental HealthServ ic e s Work, bu t A r e N o t A va i l a b l e

A wide array of mental health practices are known to work; however, mostservices delivered in Colorado – and thenation as a whole – do not incorporatethese practices. In many cases, it willrequire additional spending, providereducation and efforts to overcome the inertia of training programs and

Too few providers speak Spanish,American Sign Language and othernon-English languages.

S E V E N :

Res i l ience and RecoveryAre Important Trends

The concepts of recovery and resiliencestem from a growing national movementamong people using mental healthservices, their families, providers anddecision makers. They are lookingbeyond traditional ideas about mentalhealth services to broader issues ofhealth, community and involvement in the lives of adults with mental illnessand children with emotional disorders.The notion of recovery from mental illness is reshaping adults’ expectationsfor themselves and their treatment: people can “recover” and live satisfying,contributing, hopeful lives, even throughtheir illness is not “cured.” The “recovery”notion is based on multiple longitudinalstudies that found that approximatelyone-third of people with schizophreniasignificantly recover from their disorderand many more improve significantly.

For children and families, it has becomeincreasingly important that the mentalhealth care systems build on and promoteresilience – the ability to adapt to changeand stressful events in healthy and flexibleways. Research has found that mentalhealth services provided to children andyouth are most effective when agencieswork in partnership with each other andthe communities they serve. In recent years,a subtle shift in emphasis toward “commu-nities of care” has focused on the processof strengthening positive bonds to family,friends and community as a primary routeto a secure and productive adulthood.

Recommendations

The study makes a number of recommen-dations for those who strive to improvemental health care in Colorado, including:

A W A R E N E S S

Build awareness and understandingamong policy makers, employers andother health care decision makersregarding the extent of Colorado’s unmetmental health needs and increasingly precarious funding situation. Promotethe development and implementation ofeffective programs, reduce fragmentationin the delivery system and support thecoordination and integration of services.

F U N D I N G

Promote blended funding strategies that integrate funding and services forpopulations with multiple needs, such as the mental health, child welfare andjuvenile justice systems. Also, apply theconcept of return on investment insteadof inflation when considering the valueand effectiveness of newer and moreexpensive treatments.

T R E A T M E N T

Implement the many existing research-proven and promising programs, treat-ments and interventions. This requiresboth fidelity to what was proven, as wellas targeted modification where there arecultural differences or where resourcesare limited, such as in rural areas.

Additionally, newer treatment concepts,such as recovery and resilience, needincreased support to offer hope andstrengthen positive bonds to the commu-nity, family and friends of those sufferingfrom mental illness or emotional disorders.

P R O V I D E R S

Support efforts to recruit specializedproviders, such as child psychiatristsand competent providers for underservedcultural and linguistic groups. It is alsoimportant to look for strategies to extendexisting resources, such as telemedicinefor rural areas, additional training for primary care physicians to improve theirdiagnostic and prescribing practices,and training in cultural competency.

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The Mental Health Funders Collaborative

T O R E C E I V E A C O P Y O F T H E F U L L R E P O R T , T H E S T A T U S O F M E N T A LH E A L T H C A R E I N C O L O R A D O , G O T O W W W . C O L O R A D O T R U S T . O R G .

To r e qu e s t a d d i t i o na l c o p ie s o f t h i s H i g h l i g h t s r e p o r t , o r t o r e qu e s t p erm i s s ion to excerpt f rom th i s publ icat ion, contact The Colorado Trust at 303-837-1200.

© October 2003. The Mental Health Funders Collaborative: Caring for Colorado Foundation; The Colorado Trust; DanielsFund; The Denver Foundation, with support from the following funds: Ryan Briggs Memorial Foundation, Diana Burk VickeryCharitable Foundation, N.E.A.R. Fund and the John Jenkins & Debra Lappin Fund; First Data Western Union Foundation;HealthONE Alliance; Rose Community Foundation; and Rose Women’s Organization. All rights reserved.

Caring for Colorado Foundation

The Colorado Trust

Daniels Fund

The Denver Foundation, with support from the following funds:

Ryan Briggs Memorial Foundation, Diana Burk Vickery Chari table

Foundation, N.E.A.R. Fund and theJohn Jenkins & Debra Lappin Fund

First Data Western Union Foundation

HealthONE Alliance

Rose Community Foundation

Rose Women’s Organization